On the Cover

Patients who carry a high-penetrance melanoma predisposition gene can often benefit from screening for other cancers. Patients who receive a positive genetic test result are more likely to embrace prevention and detection measures. A new “Rules of Three” proposes a point-based guideline to help determine who should be referred for genetic counseling and testing.

In this issue

Columns

Norman Levine, M.D., notes that being a physician is not easy. A large part of the difficulty centers on the patient-doctor relationship and how one maximizes the benefits that the patient accrues by the care he receives.

Dr. Derm recently performed a fairly simple excision, discussed blood thinners, but failed to ask his patient about “natural” herbal intake. The patient did not take any prescription blood thinners, but did take high daily dosages of garlic and ginkgo. A lawsuit was brought against Dr. Derm. Can he really have liability for all the things people ingest these days?

Instructional handouts help caregivers stick to complicated treatment plans for pediatric AD patients. Historically effective AD treatments are being augmented with new phosphodiesterase inhibitors and biologics. Gentler approaches such as massage, light therapy, and melatonin may also be of value for children with AD.

Drugs to treat atopic dermatitis are at the top of the FDA’s dermatology list. Biologics and PDE4 inhibitors show promise in the treatment of AD. Approval is still needed for the use of biologics to treat AD in pediatric patients.

Phosphodiesterase (PDE) inhibitors including apremilast and crisaborole ointment may provide safer alternatives than traditional steroid-sparing agents for psoriasis and atopic dermatitis. Side effects of apremilast may include GI symptoms, weight loss and depression, and taking apremilast with anti-seizure drugs or rifampin lowers apremilast blood levels, Apremilast is being studied in inflammatory bowel disease, Behcet's disease and pediatric psoriasis, and may have a place in the treatment of hidradenitis suppurativa (HS).

With a long history in dermatology and rheumatology, TNF inhibitors can not only improve psoriasis and psoriatic arthritis, but they also may reduce comorbid cardiovascular risks and work better combined with methotrexate. Low doses of cyclosporine may be effective at treating the psoriasis reaction when topicals have proven ineffective. Aggressively managing TNF-induced reactions can help patients stay on drugs that are working for other challenging diseases.

Oncology

Cyclosporine and PUVA clearly increase the risk of squamous cell carcinomas, and there is evidence that TNF blockers and methotrexate may do so to a lesser degree. UVB phototherapy has not been shown to cause skin cancer. Acitretin offers protection against the development of basal cell and squamous cell carcinomas.

Genetic profiling is valuable in both diagnosis and prognosis of skin cancer. Hedgehog inhibitors and (superficial radiation therapy) SRT are strong contenders for treating nonmelanoma skin cancer. Advances in targeted therapies and biologics are part of the new wave of melanoma treatments.

All surgical management of melanoma is defined by Breslow thickness. For melanoma less than 1 mm in thickness, typically a SLNB is not required. Future imaging devices may better delineate the extent and depth of the tumor in vivo.

Laser for melanoma in situ (MIS) should generally be reserved for nonsurgical, usually elderly patients. When indicated, MIS may be treated with CO2 laser or with combined Q-switched Nd:YAG and imiquimod. Any atypical-appearing lesion should be biopsied prior to the start of a laser treatment.

Skin side effects from anticancer treatments can be a special burden for patients already suffering the extreme pressures of a cancer diagnosis. Treatments must be customized for patients based on the type of cancer and treatment, as well as the patient’s personal goals. Close and active relationships with patients are vital to assure the best possible outcome.

Extracorporeal photopheresis is underused for early-stage mycosis fungoides. ECP is capable of correcting the cytokine imbalance seen in patients with MF and results in an increase of Th1 cytokines. Clinicians should consider more frequent use in select patients